Medical images connect the body with other bodies, with advanced technologies, medicine and the visual field. They defy any easy singular definition. They are multiple things: a diagnostic aid, a monitoring tool, an interior abstraction, a medical document, a trace of an intervention, an image of the body, a visualised data set. I can’t disentangle what they are from what they do.
And the medical body is on the threshold of change as the computer sciences become more integral to healthcare.
In this project I am trying to re-think and re-imagine the relationship between the body and the medical image; to overcome the traditional separations that divide the body from its image, the so
Medicine and imaging have been entangled in shaping the evolution of the other, and the visual has had a consistently privileged position both within medical practices and education. Through artist drawings, anatomical illustrations, photography, radiography or digital imaging, the history of medicine can be understood as an ongoing endeavor to comprehensively visualize disease and the body.
From the eighteenth century onwards, going into the body has meant going into the image first. (1)
Up to a point, a medical image is comparable with other forms of digital imaging: there is an identified subject, an area of focus, a process of capture and image-formation. It results in a standardized visual output. But in other ways the medical image is distinctive. It is dependent on highly specialized technologies (some of which are inherently non-visual); trained operators; tightly controlled conditions and numerous institutional protocols. The subject of the image – the patient – often never sees the image. And even if they do, it is beyond comprehension, requiring the expert analysis of the radiologist. The medical image visibilises to others, that which is invisible to ourselves.
The gaps in medical imaging, between the subject and the image, and the subject and viewer, mean it is sometimes compared to certain forms of monitoring and surveillance. This to acknowledge overtones of voyeurism in medical imaging, but it overlooks the ways in which we are knowing, consenting subjects, complicit in the image through concerns about health and the possibilities of recovery.
The earliest form of internal medical imaging was the x-ray, invented by Roetgen, and adopted after some time as a potential diagnostic tool. The x-ray is a record of variations in density, produced through a deflected [or projected] image. From the outset, Roetgen fixed his early radiographs onto photographic surfaces, and photography became the medium through which x-rays circulated. Photography and radiography became so linked together that by the end of the nineteenth century they seemed to merge, and were often confused. Photographers set up x-ray studios, offering x-ray imaging to the public for a range of medical and non-medical purposes. The Lancet hailed x-rays as ‘The New Photography’, and adverts offered ‘Photography of the Unseen’ or ‘Photography of the Invisible’ to fascinated public and scientific audiences. This somewhat erroneous analogy helped lend to x-rays something of photography’s growing reputation as a medium of veracity and authority.
Initially, the status of the x-ray was uncertain. As early 1897, shortly after the x-ray’s invention, a patient sued a doctor who had failed to diagnose a fracture in his leg. The prosecution arranged for an x-ray of the injury and then submitted that x-ray to the court as evidence of medical negligence. The value of the x-ray as was questioned by one of the judges. ‘It is like offering a photograph of a ghost, where there is no proof that there is any such thing as a ghost.’ The image didn’t prove the existence of the injury because the injury couldn’t been seen independently, to verify the truth of the image. In other words the x-ray didn’t have the evidential authority of proof.
What Smith’s case makes clear is the X-ray’s peculiar condition as a representation….the data the X-ray provides is virtually unverifiable. (2)
Though the case was eventually won, the value and use of x-ray images in the early days had to be established through ongoing comparisons with the actual body. Through surgery and autopsies, images were analysed against flesh, and doctors began learning this new language of shadows. There was no sense in which the x-ray was self-explanatory, its interpretive use being established over time. Though early x-rays were of quite poor quality, the medical and scientific possibilities of the x-ray were immediately apparent. The earliest widespread use of x-rays was in diagnosing TB, and by 1900 most sanitoriums where TB patients were treated, were equipped with an x-ray machine.
X-rays changed medicine, especially the relationship between doctor and patient. Diagnosis had previously been based primarily on sensory modes of investigation, including touch/palpation, observation, and listening to patient description. X-rays promised a new kind of diagnosis based on mechanical vision, subordinating the subjective experiences of patients to the authority of the image. Doctors became seeing specialists. For TB, early studies showed that x-rays were quickly shown to diagnose patients with greater (though still far from total) accuracy than the methods of ascultation and percussion that it displaced. Perhaps such improvements in diagnosis obscured the fact that mis-readings and variations in interpretation remained common. (Even today, despite the enduring idea of the x-ray as evidence, radiologists are happy to admit their opacity and ambiguity).
X-rays and other types of medical images fueled an already-established tradition of the body’s insides as a spectacle, throughout the twentieth century. From public surgeries through to the regular use of radiographs in a rapidly expanding popular and scientific press, bodily interiors have been part of a widespread and ongoing cultural fascination. In the early days, it was popularly thought that a x-ray had the potential to reveal something of a person’s character and passions, and even fortell their death. Through widespread circulation of x-ray of skeletons, breached the boundaries between life and death, bringing them into a visible relation.
X-rays transformed the relationship between vision and the medical body, connecting (more than any other previous medium) bodies directly to images. They were the first means by which internal anatomy was made visible without cutting into the body, leaving the surface intact. This capacity to transcend the body’s boundaries imbued x-rays with ideals of transparency and notions of visual power. They became understood as providing objective accounts of illness, without [too many] problems of bias or subjectivity. This perceived objectivity fitted easily within a predominantly scientific model of medicine, conceptualising technology as a disinterested mediator between the patient and the doctor, in which the patient is an object to be studied and measured. This model forges a linear relationship between seeing and knowing, combining an idea of technology’s neutrality with medicine’s detachment. The more we can see, the better we can know.
As if the truth consisted simply in making something visible. (3)
The implicit separation of the observer and the observed in this model mirrors other dualities in the era of modern science: the natural and the cultural; the world and the image; the material and the digital; the biological and the social; the body and the mind. In medicine this dualism is most strongly expressed in the form of the doctor as the all-seeing (and therefore all-knowing) active subject and the patient as the passive, known object. Technology is assigned as an invisible or benign force, mediating between the knower and the known, as if it is somehow external to reality, reflecting or mirroring that reality but not part of it. The image reveals the patient to the doctor, leaving both unchanged by the event. The persistence of this dualistic mode of thought helps explain the ongoing problem of medicine’s focus on biological disease to the exclusion of experienced illness.
A critique of the mechanical-clinical gaze has been most powerfully theorized by Foucault in his book the Birth of The Clinic, building on previous analyses of the institutions and practices of power. Foucault challenged many conventional scientific assumptions about medicine as founded on observations of truth about the patient’s body. He took the inverse view that medicine, and in particular the practices and technologies of observation and analysis, contribute to social constructions the body. In entering the field of human knowledge, the body becomes subject to relations of power. Foucault transformed thinking about the relationship between bodies and medicine. He argued that modern medicine effectively detaches the body from the person, creating a false, subjugating dichotomy by which the patient’s body becomes both an effect and object of medical inquiry.
The sociologist David Armstrong developed further Foucault’s ideas about the relationship between illness and representation. He argued, in a reversal of conventional understanding of the direct of relations between an object and its image that the medical atlas – the foundation of student learning in medicine – is not a representation of the body, but the body is a representation of the atlas. Students’ understanding of the body is learnt through the frame of such representations, in which the body is encountered as a series of discrete, sequential objects. Much of their primary knowledge of the body comes from such inscriptions, before they go on to practice on real bodies. In Armstrong’s analysis, the medical body is constructed through, and an effect of, this observing clinical gaze. It is as if the reality of the body is produced through objects of study. His argument disturbed the generally accepted idea that the body’s reality precedes any representation, proposing that its is emerges through representation.
Embedded in these different accounts of the medical body are different philosophies of nature of technology, representation and the body. Unifying many of them is the underlying concept that the social and biological are opposed and separate fields, acting on each other in different ways. Often images are thought to mediate these two domains, either as neutral objects or as agents of domination.
In this project I am interested in a different and more openly subjective account of the medical image. One of the broad aims of Digital Insides is to speculate on how technologies of imaging are implicated in our very understanding of what the body is. Like many others writing from a cultural, anthropological or sociological perspective, I prefer to think about the image as an entanglement of bodies, technologies and medical practices.
This way of understanding images moves away from static notions of representation, and from linear explanations. It allows us to see medical images as generative rather than relfective of realities. It implicates the image in fluctuating definitions of self/illness/wellness. Images are an integral part of the reality they seek to understand.
Contemporary medicine doesn’t simply use imaging, rather it is itself an imaging technology, a way of seeing and interpreting bodies. (4)
But [medical] images are more than representations. They are interventions with material effects for observers and for the observed. Useful here is Latour’s idea of inscription, in which ‘the image cuts into the body marking it indelibly’. Latour does not mean this literally, but is emphasising the way images have consequences on living, experiencing bodies that do things and move around in the world. It allows us to understand medical imaging as a charged interaction where multiple subjectivities unfold. Where material and social practices are enacted through,with and on bodies that are simultaneously biological and social at all times.
There is no reference to a [pure] body which is not at the same time a further formation of that body. (5)
From this more vital standpoint, looking back, we can see that the x-ray didn’t just represent a visual and technological advance, it radicalized the very idea of the human subject. Not only did it demonstrate the limitation of human perception compared with machine vision, it collapsed the long established distinction between an invisible interior and visible exterior. The body, which had for a long time been regarded as a ‘container for the self’, was ruptured. The surface that had demarcated the boundary between the body and the world was breached, or collapsed, through the image. That same surface was taken into the image of the interior as a form of shadow, (or shadow of a form). The simultaneous view of the inside and outside erased an established limit, and turned the vantage of the spectator-subject inside out. The subject had become the focus of its own penetrating look.
In transgressing the boundaries of the skin, the x-ray troubled the very definition of the subject upon which much Enlightenment thought was based. (6)
So, conceptually the body was disassembled, or changed from the outside in. Michael Frizot argued along similar lines that the x-ray troubled the very foundation of modern thought, through its double invisibilities: the invisible force of the rays visibilising the invisible interior of the body.
The x-ray, then, upset the conventional order of representation. What was previously unseen became the real, whereas the seen became a mere surface, a screen or veil to a deep knowledge within. (7) To bring the surface – associated with apperances – together with the interior – associated with inner most truth – in the same visual plane was a loss/shift not only of visual, but social perspective.
There have been numerous other important social and cultural histories of the x-ray: its links to early cinema and surveillance of women’s bodies; its relationship to psychology; its relevance to the work of Duchamps and the early cubist movement; its gendered practices and ideaologies that differentiated and visibilised female bodies for male speculation; and especially its complex and often contradictory relationship to photography. All of these histories recognise the ways in which the x-ray was a contested social as well as technological field, with profound and far-reaching and specific effects.
Following on from such accounts and histories, I am interested in how subsequent generations of digital imaging – such as CT, MRI and other modalities – continue to push as the boundaries of visibility and enact further changes in definitions of the body. Via the screen imaging is making the body increasingly manipulable, navigable, calculable and accessible. Image scans are making up an increasingly important source of digital biomedical data.
Computerisation and digitization affect all aspects of medicine but imaging in particular is transformed by the ability to record, store, analyse and share patient images as data. Bodies exist as transmittable code across numerous files, dispersed in digital structures, and can be visually reassembled in the space of the screen, anywhere, in an instant. It can be animated, reproduced, written and rewritten with limit [but contrained by privacy, regulation and ethical codes].
But my interest is not only in the technologies per se, nor in the creation and processing of individual patient images, but also in how rapid economic changes have enabled a new convergence of interests between engineering, computer sciences, media and medicine. Computer software and hardware systems operating across different sectors, through common platforms and constantly expanding networks, allow for an unprecedented integration of interests and systems in medicine. The body is becoming part of this new informational economy, facilitated through new forms of biomedical management. It is being propelled into the fields of medical image computing, post-image processing, computer aided diagnosis, automated analysis, image-guided surgery/treatment, machine and deep learning, and image mining. The image is the potential: in a computerised system, it is becoming generative in new ways, both as product and process.
These fast-emerging and developing technologies and processes are based to differing degrees on machine intelligence. Computers are increasingly involved in creating, processing, assessing, analysing, diagnosing and predicting images and image-based outcomes than ever before. Many of these automated tasks are programmed through well-known algorithms but increasingly, notably in medical research, machine learning is driving new knowledge. Computers can operate consistently at levels of automation, detection and speed that far exceed human capabilities. They can find and build on patterns and similarities within hugely variable data sets [bodies] that humans cannot. These various human/non-human collaborations are particularly challenging in the clinical field – huge anatomical variations make it difficult to regularise pattern recognition. So the lived body is both resource and obstacle to advances in machine learning.
All this is making the body knowable and accessible in new ways. It is tranforming the body and the space of medical thought itself. ( )
The questions are numerous:
What of the relations between human and non-human, bodies and technologies?

P9
How do we understand the agency and materiality of the medical body in an era of algorithms and machine learning?

1. Roberta McGrath. Seeing Her Sex: Medical Archives and the Female Body. Manchester University Press, 2002.
2. Corey Keller. The Naked Truth or the Shadow of Doubt?: X-Rays and the Problematic of Transparency. InVisible Culture: An Electronic Journal for Visual Culture. Issue 7. 2004.
3. Rosi Braidotti. Nomadic Subjects: Embodiment and Sexual Difference in Contemporary Feminist Theory. Columbia University Press. 2011.
4. Elizabeth Stephens. ‘Anatomical imag(inari)es: the cultural impact of medical imaging technologies’. Somatechnics, vol. 2, no. 2, pp. 159-170.
5. Judith Butler. Bodies That Matter: On The Discursive Limits of Sex. Routledge, 2011.
6. Akira Mizuta Lippet. Phenomenologies of the Surface: Radiation-Body-Image. Qui Parle. Vol 9, no 2. 1996
7. Sander Gilman quoted in Roberta McGrath. Seeing Her Sex: Medical Archives and the Female Body. Manchester University Press, 2002.